Provider Demographics
NPI:1528625407
Name:GARDNER, KYLE (DC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4316 JAMES CASEY ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1116
Mailing Address - Country:US
Mailing Address - Phone:512-442-2727
Mailing Address - Fax:512-442-2728
Practice Address - Street 1:4316 JAMES CASEY ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1116
Practice Address - Country:US
Practice Address - Phone:512-442-2727
Practice Address - Fax:512-442-2728
Is Sole Proprietor?:No
Enumeration Date:2019-05-25
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14129111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14129OtherSTATE LICENSE